Evaluating Community Health Centers' Adoption of a New Global Capitation Payment (eCHANGE)

The investigators are conducting a prospective analysis of the Alternative Payment Methodology (APM) demonstration project sites. The investigators' goal is to conduct a cross project analysis of findings. The investigators propose to use mixed methods to study processes and outcomes associated with the APM natural experiment in payment reform. The investigators hypothesize that Community Health Centers (CHCs) participating in the APM demonstration project will redesign their workflows to better focus on patient and population health needs, resulting in reallocation of financial resources, lower overall costs, changes in utilization patterns, and improved quality.

Study Overview

• Status: Unknown
• Conditions: Chronic Diseases
• Intervention / Treatment: Other: Alternative Payment Model

Detailed Description

Led by the Oregon Primary Care Association, three community health center (CHC) organizations in Oregon developed an Alternative Payment Methodology (APM). Under this APM pilot participating CHCs will receive a prospective payment system (PPS) payment as a capitated equivalent in a per-member-per-month rate for all of their Medicaid patients. Oregon CHC organizations (several clinic sites) implemented Phase I of this demonstration project on March 1, 2013; Phase II A was implemented on July 1, 2014; Phase II B on October 1, 2014; and Phase III began July 1, 2015.

We are a prospective analysis of the APM project sites. We propose to use mixed methods to study processes and outcomes associated with the APM natural experiment in payment reform. We hypothesize that CHCs participating in the APM demonstration project will redesign their workflows to better focus on patient and population health needs, resulting in reallocation of financial resources, lower overall costs, changes in utilization patterns, and improved quality.

The study will include baseline qualitative data collection as clinics are transitioning to the APM methodology. We will conduct 2 site visits to each intervention clinic to observe practice changes that occurred post APM-implementation (first visit approximately 12-18 months post-APM implementation; second visit approximately 30-36 months post-APM implementation). We will also assemble and analyze of pre-post quantitative and qualitative datasets, and interpretation and dissemination of study findings.

• Study Type: Observational
• Enrollment (Anticipated): 400000

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 2 years to 64 years (Child, Adult)
• Accepts Healthy Volunteers: Yes
• Genders Eligible for Study: All

• Sampling Method: Non-Probability Sample

Study Population

Community Health Center (CHC) and clinic patients of which CHCs are participating in the APM demonstration (intervention) or are matched with APM CHCs (control)

Description

Inclusion Criteria:

1. Total clinic population:

   established patients at intervention and control clinics aged 2-64

2. Medicaid Population:

Medicaid-enrolled patients at intervention and control clinics aged 2-64

Exclusion Criteria:

1. Total clinic population:

   non-established patients at intervention and control clinics aged 2-64

2. Medicaid Population:

non-Medicaid-enrolled patients at intervention and control clinics aged 2-64

Study Plan

How is the study designed?

Number of groups / cohorts

2

Cohorts and Interventions

Group / Cohort	Intervention / Treatment
Control Group - non-intervention; Clinics that did not participate in the APM project
Alternative Payment Model -intervention; Oregon developed an Alternative Payment Methodology (APM). Under this APM pilot participating CHCs will receive a prospective payment system (PPS) payment as a capitated equivalent in a per-member-per-month rate for all of their Medicaid patients	Other: Alternative Payment Model; Oregon developed an Alternative Payment Methodology (APM). Under this APM pilot participating CHCs will receive a prospective payment system (PPS) payment as a capitated equivalent in a per-member-per-month rate for all of their Medicaid patients

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Internal services utilization	Number and type of internal services utilized including number and ratio of "traditional" face to face visits vs. "nontraditional" encounters and communication via phone, personal health record, and email	≤3 years pre-APM implementation and ≤3 years post

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Quality care measures	We selected measures that are: 1) identified by Oregon's Medicaid program and/or those on the list of Clinical Quality Measures in the electronic health record (EHR) incentive programs; 2) feasibly measured with EHR or Medicaid claims data; 3) representative across age groups and gender; 4) representative of treatment levels (e.g., prevention, acute and chronic condition care); and 5) relevant to CHC populations.	≤3 years pre-APM implementation and ≤3 years post
External services utilization	Number and type of external services utilized including percent of patients with a follow-up appointment after discharge and average wait time	≤3 years pre-APM implementation and ≤3 years post
Medicaid expenditures	We will calculate the average pre-post APM difference in total Medicaid expenditures attributable to the subpopulation of Medicaid-insured patients in APM intervention clinics, subtracted by the average difference among Medicaid-insured patients in comparison clinics	≤3 years pre-APM implementation and ≤3 years post

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Study the change processes associated with APM implementation	Qualitative assessment of practice change through interviews and site visits	≤3 years pre-APM implementation and ≤3 years post

Collaborators and Investigators

• Sponsor: Oregon Health and Science University
• Collaborators: Robert Wood Johnson Foundation; Agency for Healthcare Research and Quality (AHRQ); OCHIN, Inc.
• Investigators: Principal Investigator: John Heintzman, MD, MPH, Oregon Health and Science University; Study Director: Heather Angier, MPH, Oregon Health and Science University

Publications and helpful links

General Publications

• Heintzman J, Cottrell E, Angier H, O'Malley J, Bailey S, Jacob L, DeVoe J, Ukhanova M, Thayer E, Marino M. Impact of Alternative Payment Methodology on Primary Care Visits and Scheduling. J Am Board Fam Med. 2019 Jul-Aug;32(4):539-549. doi: 10.3122/jabfm.2019.04.180368.
• Angier H, O'Malley JP, Marino M, McConnell KJ, Cottrell E, Jacob RL, Likumahuwa-Ackman S, Heintzman J, Huguet N, Bailey SR, DeVoe JE. Evaluating community health centers' adoption of a new global capitation payment (eCHANGE) study protocol. Contemp Clin Trials. 2017 Jan;52:35-38. doi: 10.1016/j.cct.2016.11.001. Epub 2016 Nov 9.
• Cottrell EK, Hall JD, Kautz G, Angier H, Likumahuwa-Ackman S, Sisulak L, Keller S, Cameron DC, DeVoe JE, Cohen DJ. Reporting From the Front Lines: Implementing Oregon's Alternative Payment Methodology in Federally Qualified Health Centers. J Ambul Care Manage. 2017 Oct/Dec;40(4):339-346. doi: 10.1097/JAC.0000000000000198.

Study record dates

Study Major Dates

• Study Start: July 1, 2015
• Primary Completion (Anticipated): May 1, 2020
• Study Completion (Anticipated): May 1, 2020

Study Registration Dates

• First Submitted: December 2, 2015
• First Submitted That Met QC Criteria: December 17, 2015
• First Posted (Estimate): December 22, 2015

Study Record Updates

• Last Update Posted (Actual): October 14, 2019
• Last Update Submitted That Met QC Criteria: October 10, 2019
• Last Verified: October 1, 2019

More Information

Terms related to this study

• Keywords: Health Care Utilization; Health Care Quality, Access, and Evaluation; Prospective Payment System; Health Expenditures
• Additional Relevant MeSH Terms: Pathologic Processes; Disease Attributes; Chronic Disease
• Other Study ID Numbers: AHRQ R01HS22651; 71125 (Other Grant/Funding Number: AHRQ)